Healthcare Provider Details

I. General information

NPI: 1629040381
Provider Name (Legal Business Name): GREGORY LEE WATFORD D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/06/2006
Last Update Date: 03/07/2025
Certification Date: 03/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

871 USS JAMES MADISON RD
KINGS BAY GA
31547-2531
US

IV. Provider business mailing address

26 LONDON HILL LN
WOODBINE GA
31569-3926
US

V. Phone/Fax

Practice location:
  • Phone: 912-510-0679
  • Fax:
Mailing address:
  • Phone: 912-510-0679
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License NumberDN010254
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDN010254
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: